Living, Leading & Medicine: A two-tiered leadership development programme for family medicine residents.

BACKGROUND: There is increasing awareness of the necessity and importance for physician leadership in health care. Despite this, formal leadership training is not widespread in medical education. APPROACH: We describe the structure, curriculum and development of a robust two-tiered leadership development programme within a community-based family medicine residency programme. Living, Leading & Medicine (LLM, tier 1) consists of nine 2.5-h discussion-based training sessions occurring thrice annually. The Advanced Leadership Track (ALT, tier 2) includes mentoring, additional readings, personal evaluations and leadership projects. EVALUATION: We used post-session surveys and exit surveys for LLM and ALT, respectively. We utilised the modified Kirkpatrick framework for programme evaluation to present outcomes from the first 3 years for each tier. Over three quarters (40 out of 53) of residents participated in LLM sessions. The post-session survey response rate for LLM was 95% (124 out of 130 participants). Eighteen out of 33 residents (54.5%) completed the ALT. Of these, 72% (13 of 18) returned exit surveys. Residents found the programme valuable and relevant (Kirkpatrick level 1). Residents demonstrated improvements in leadership knowledge and skills (3.85 v. 3.11, p < 0.0001; Kirkpatrick level 2) compared with an internal, historic control group. We noted changes in resident behaviour and attitudes towards leadership (Kirkpatrick level 3). Finally, the completion of leadership projects demonstrates Kirkpatrick level 4 outcomes. IMPLICATIONS: We have created a longitudinal, two-tiered leadership development programme that has improved the leadership capabilities of our family medicine residents.

Financial challenges in the family physician programme in Iran: A systematic review of qualitative research.

Introduction: The family physician programme (FPP) was implemented nearly two decades ago as a major health reform. Since the health system and FPP function in a rapidly changing social and economic environment, successful expansion of the programme requires a detailed analysis of its multiple major challenges, including the crucial aspect of its funding system. This systematic review aimed to assess the challenges in the FPP relative to its financing. Method: All published articles related to the FPP in Iran were included in this study. In particular, original qualitative studies published in English or Persian from 2011 to 2021 were included. In January 2022, international credible scholarly databases and Persian databases were searched. All selected articles were carefully studied, and the data were extracted using the sample, phenomenon of interest, design, evaluation and research type technique. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses were used in preparing the study report. Results: Among 491 articles retrieved from the search strategy, 50 met the inclusion criteria after their titles and abstracts were screened. Twenty-nine studies were excluded after their full texts were reviewed. A total of 11 eligible empirical studies were finally included. Based on the results, six broad categories (budget and funding, insurance system, tariffs, payments, accountability and injustice) were identified as financial challenges. Conclusion: This study identified the challenges associated with financing among family physicians, and the results could provide guidance for policy-making in the expansion of the FPP.

Burnout Among South Dakota-Licensed Physicians.

INTRODUCTION: Physician well-being is a topic of increasing attention nationwide. In collaboration with the South Dakota Board of Osteopathic and Medical Examiners and the South Dakota State Medical Association, we undertook an anonymous, web-based survey of all licensed physicians to assess the current baseline level of physician burnout. METHODS: The survey consisted of demographic questions and a single, validated burnout question that correlates with the lengthier Maslach Burnout Index. A link to take the survey was emailed to all licensees by the Board, and a single reminder email and link was sent two weeks later. The collector was open for 4 weeks from date of the initial invitation. Both quantitative and qualitative analyses were performed on the responses. RESULTS: There were 612 responses (10%). Overall 33.0% of responses were positive for burnout. Comparing subgroups divided by average work hours, practice size, community size, geographic location within the state, employment status, and specialty type, only those practicing primarily telemedicine demonstrated statistically significant lower prevalence of burnout (17%). Qualitative analysis identified themes that both increased risk and offered protection against burnout, including sense of control, availability of resources, relationships, and meaning in work. CONCLUSION: Burnout among physicians licensed by South Dakota is prevalent, though lower than the rate reported in most studies of physicians nationally. Apart from practicing primarily telemedicine, there was no correlation between burnout and practice characteristics, but provoking and palliating factors across practice types were identified that may offer potential areas for intervention to improve wellness.

Travel Medicine: Pretravel Counseling for Healthy Travelers.

Before the COVID-19 pandemic, international travel was increasing at a brisk rate. After a lull, it is picking up again and predicted to continue to climb as it had previously. International travel presents some unique health hazards, including infectious diseases, chronic disease exacerbation, environment-related illness, accidental injuries, and transportation-related illness. Many travelers appropriately seek medical consultation for advice and interventions to decrease their health risks during travel. The pretravel consultation consists of risk identification and preventive interventions. Although these consultations traditionally have occurred with infectious disease specialists, family physicians can and should provide this care. Pretravel consultations should review a patient's medical conditions, how travel can affect them, and what the patient can do to address medical needs that may arise while abroad. Balancing the risks likely to be encountered with the individual traveler's risk tolerance, patients and family physicians can collaboratively develop a strategy to mitigate these risks and increase the likelihood of an uneventful (and enjoyable) sojourn.

Near Two Decades of the Family Physician Program in Iran and the Structural Challenges: A Systematic Review.

The family physician program (FPP) is one of the most significant health care reforms in Iran; however, many studies showed that this program has not been able to achieve its intended objectives because of a variety of challenges. This program, despite the existing challenges, is going to be expanded across the country. To improve the likelihood of its success, identification of the structural and infrastructural challenges is necessary. This systematic review was conducted to assess the structural and infrastructural challenges of FPP in Iran. This systematic review of the literature was conducted in order to investigate the infrastructure and structure needs of the current program in Iran. All published articles related to the FPP in Iran were the subject of this study. The eligibility criteria included original articles, reviews, or case studies published in English or Persian during 2011-2021 related to the challenges in the referral system of FPP in Iran. Data were extracted based on Sample, Phenomenon of Interest, Design, Evaluation, Research type technique and were reported based on the structure of Preferred Reporting Items for Systematic Reviews and Meta-Analyses. International credible scholarly databases were searched. The search strategy was defined based on keywords and the search syntax. This study identified different challenges of the referral system in the areas associated with legal structure, administration, and social structure. The identified challenges in this program should be addressed in order to ensure that this program will lead to improved quality of care and equity in Iran health care system.

Case report and literature review: Genital leishmaniasis.

The majority of genital ulcers are caused by sexually transmitted infections, though there are also other infectious and noninfectious etiologies. We present here an unusual cause of a penile ulcer due to cutaneous leishmaniasis, along with a review of the literature regarding such cases. The patient recovered following timely initiation of treatment. Rapid diagnosis of this case was aided by occurring in the context of a concurrent outbreak of cutaneous leishmaniasis in the region in which the patient resided.

Improving Rates of Vitamin D Supplementation in Somali Immigrant Infants: A Prospective Interventional Pilot Trial.

PURPOSE: Rates of vitamin D deficiency and nutritional rickets have been rising over the past several decades, particularly in high-risk infants. This pilot study assessed the impact of providing free vitamin D supplements, a culturally-appropriate educational brochure, and a brief counseling session about the importance of both vitamin D supplementation and breastfeeding to the parents of Somali infants at routine office visits from newborn through 6 months of age at three Federally Qualified Health Centers in Colorado. We also assessed the impact this intervention had on rates of breastfeeding. METHODS: Twenty-five Somali infants aged 24 weeks or less were identified by searching electronic health records and enrolled into a historic control group. The parents were then surveyed by phone regarding breastfeeding and vitamin D supplementation. Subsequently, 37 families with newborn Somali infants were identified and enrolled into the intervention arm of the trial. RESULTS: The intervention group had a higher rate of vitamin D supplementation compared to the historical control group (67 vs. 48 percent, p=0.011) without significantly impacting breastfeeding rates. CONCLUSION: These results suggest a practical way to increase vitamin D status in this high-risk population. Trial not registered as it was a pilot study, not a phase II to IV prospective clinical trial.

Mothers in Medicine: Breastfeeding and the Healthcare Professional.

Breastfeeding mothers in the healthcare field face significant and unique challenges. This paper seeks to highlight many of these challenges and illustrate examples of systemic changes that can improve breastfeeding success. This is important, because there are many benefits of breastfeeding. From individual and system-wide cost savings to health benefits for mom, baby, and society, increased breastfeeding success within their workforce is a goal that healthcare systems should pursue.

A Simple Intervention to Increase Human Papillomavirus Vaccination in a Family Medicine Practice.

Human papillomavirus (HPV) is a sexually transmitted virus that is the leading cause of cervical cancer world- wide. It is vaccine-preventable. According to the Centers for Disease Control, only 60 percent of girls have started the HPV vaccination series countrywide and only 50 percent of boys have started. South Dakota is below this national average. In an effort to assess - and improve - HPV vaccination rates in our practice a quality improvement effort was undertaken. Two interventions were implemented a month apart: the first was a mailing to the parent(s) of all patients 11-12 years of age during the time period of the intervention; the second was an in-office reminder system for both patients and physicians at the time of an office encounter. After each of the interventions, the immunization rate for one injection was significantly greater than baseline; while slightly higher than baseline, that for those receiving both injections was not statistically different for either intervention.

Development of Leiomyosarcoma in a Patient Treated with Azathioprine.

Cirrhosis resulting from autoimmune hepatitis is associated with an increased risk of hepatocellular carcinoma. A common treatment for autoimmune hepatitis, azathioprine, is also associated with the development of many other cancers, predominantly lymphomas. The strongest association is seen for post-transplant lymphoma and hepatosplenic T-cell lymphoma in Crohn's disease and ulcerative colitis patients; there is also an association with a variety of cutaneous malignancies. A relationship between azathioprine and sarcoma has not been demonstrated, though there have been sporadic case reports. We report here the development of leiomyosarcoma in a patient who was treated with azathioprine for autoimmune hepatitis without cirrhosis.

Family Physician Burnout Rates in Rural versus Metropolitan Areas: A Pilot Study.

PURPOSE: Physician burnout is prevalent in family physicians. Burnout has been associated with an intent to leave practice location. This is especially concerning in many rural areas, which already have physician shortages. While other demographic characteristics of burnout have been assessed, no previously published studies were found that have specifically compared family physician burnout rates in rural versus metropolitan areas. We hypothesized that rural family physicians have higher burnout rates due to increased practice demands and lack of resources. METHODS: Three hundred and two graduates of a Midwest family medicine residency program were surveyed to assess burnout rates in rural (practicing in towns less than 10,000 people) versus medium-sized towns (10,000- 50,000 people) and metropolitan areas (greater than 50,000 people). Burnout was determined by a one question assessment tool that has been validated with the Maslach Burnout Inventory Emotional Exhaustion Index. FINDINGS: Ninety-nine surveys were completed. Twenty-five percent of rural respondents reported burnout, compared to 37.5 percent of respondents in medium-sized towns, and 51.4 percent of respondents practicing in metropolitan areas. These results were statistically significant (p value=0.0183). CONCLUSION: These results were unexpected and may indicate that a rural practice location has a positive effect on physician well-being, which could encourage physicians to pursue rural practice. A larger study of this issue would be beneficial.

Extensive Bilateral Nodular Lung: A Diagnostic Challenge.

An elderly female presented to the emergency department with a two-month history of dyspnea on exertion and productive cough. Imaging revealed miliary nodular pattern involving both lungs. She underwent extensive work up evaluating different possible pathological processes. The condition was ultimately lethal. In this educational case report, we review the common - and not-so-common - etiologies that might present with this constellation of signs and symptoms, along with the diagnostic strategies and thought processes used to identify the final diagnosis.

Enhancing Immunization Rates for Senior Citizens in South Dakota Family Medicine Residency Practices.

BACKGROUND: The Sioux Falls Family Medicine Residency serves a large non-English speaking and low socioeconomic status population. We designed a quality initiative to increase influenza and pneumonia vaccination rates in our elderly patients. METHODS: The main components of the project included improved clinic workflow, physician and staff education, and heightened patient awareness of vaccination importance. For the latter, we employed posters with key points about why patients should receive the vaccines, and personalized handouts with a photo of their provider discussing the importance of receiving these vaccines. The handouts were translated into the four most common non-English languages served by our clinics. RESULTS: Following implementation of the initiative, influenza vaccination rates increased from 35 to 53 percent, PPSV23 vaccination rates increased from 62.5 to 64 percent, and most impressively, PCV13 vaccination rates increased from 40 to 60 percent. CONCLUSION: This quality improvement project demonstrated meaningful change with minimal financial and logistical investment and should be sustainable in the long-term.

Emerging Trends in Clinical Tropical Medicine Research.

The American Society for Tropical Medicine and Hygiene recently inaugurated an award for the best clinical research article published in the society's journal in the previous year. This article summarizes both the process of selecting the winner and several themes that stood out in those articles which rose to the top for consideration. Themes of note included the importance of doing clinical research outside of referral centers, the complexity that must be considered when implementing interventions, incorporation of both ends of the age spectrum into studies, and considering cost-effectiveness and opportunity cost of interventions.

Infectious Disease: Mosquito-Borne Viral Illnesses.

Due to rapid globalization and ease of travel, mosquito-borne viral infections are now a concern for family physicians throughout the United States. Zika virus infection is one such concern. It is spread via mosquito bites or by sexual contact with an infected individual. Most patients are asymptomatic, and when symptoms occur, they are mild and nonspecific. The main concern is the potential of the infection to cause fetal anomalies. Dengue is another mosquito-borne viral infection. Symptoms of initial infection are mild, and may include arthralgias. Subsequent infection with a different serotype can cause life-threatening hemorrhagic fever or shock. Chikungunya virus infection is widespread in the Americas and symptoms are similar to those of dengue. However, it can cause a postviral chronic inflammatory rheumatism in up to half of patients. Yellow fever occurs mostly in sub-Saharan Africa and can cause hepatic failure. Encephalitis viruses, most commonly West Nile in the United States and others such as Japanese encephalitis virus, can cause neuroinvasive disease, most often in older adults. Vaccines are available for yellow fever and Japanese encephalitis viruses but the keys to prevention are insect avoidance, mosquito eradication, and use of mosquito repellants.

Infectious Disease: Health Care-Associated Infections.

Health care-associated infections (HAIs) are a major cause of morbidity and mortality, with 2 million US patients per year developing HAIs. This results in 90,000 deaths and billions of dollars in preventable expenses annually. Common HAIs include central line-associated bloodstream infection, catheter-related urinary tract infection, surgical site infection, hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), methicillin-resistant Staphylococcus aureus (MRSA) infection, Clostridium difficile infection (CDI), and others. Many factors contribute to HAIs, including inadequate hand hygiene by health care workers, inappropriate antibiotic use, increasing prevalence of multidrug-resistant organisms (MDROs), suboptimal disinfection and cleaning of hospital rooms and equipment, and use of invasive medical devices. HAP and VAP together represent the most common HAIs. Control of HAIs involves high- and low-tech solutions, including pulsed xenon light as a room disinfection adjunct, improving health care worker adherence to hand hygiene and standard precautions, as well as regular cleaning of cell phones and stethoscopes. Antibiotic stewardship programs have been shown to reduce inappropriate prescribing of antibiotics, a significant contributor to MDROs and CDI. Bundled interventions to control MRSA and CDI have been effective. Artificial intelligence applications likely will be involved in identification of patients at risk of HAIs in the future.

Infectious Disease: Bedbugs, Lice, and Mites.

Bedbugs, mites, and scabies are ectoparasites that commonly affect humans. Bedbugs (Cimex species) were once rare in the United States but are now common. They cause intensely pruritic lesions on areas of exposed skin. The bites are highly allergenic and can cause asthma exacerbations or anaphylaxis. Management of bedbug bites involves symptomatic relief of itching and dealing with patient anxiety. Identification and elimination of infestation are most important. Another ectoparasite of concern is lice (Pediculus and Pthirus species), which causes head, body, and pubic infestations. Patients can experience hypersensitivity to the saliva of lice, but such symptoms often do not develop until several weeks after infestation. Diagnosis involves identification of nits (ie, eggs) or lice on the skin or hair. Several pediculicides are used for management but wet combing without use of pediculicides may be more effective. A third common ectoparasitic infestation, scabies (ie, infestation with the mite Sarcoptes scabiei), affects 5% of the world's population. Patients present with pruritic lesions in skin folds, finger webs, and areas in which clothing is tight. The diagnosis can be confirmed with dermatoscopy or microscopy. Management involves use of permethrin cream, oral ivermectin, or benzyl benzoate.

Infectious Disease: Community Response to Emerging Infectious Diseases.

Emerging infectious diseases are those that are newly discovered, recently have increased in prevalence, or are expected to increase in prevalence in the future. Family physicians play an important role in leading community response to emerging infectious diseases. As with other types of disasters, the general approach to outbreaks has four stages: preparedness, response, recovery, and mitigation. Preparedness includes promotion of community health, maintenance of high vaccination rates, development of protocols for hospitals and family medicine practices, preparation of patients for international travel, and consideration of volunteering in case of disasters. Response includes treatment of infected patients, minimization of the risk of transmission to other individuals, education of the public, and disease reporting to local health departments. Recovery can be physical and emotional. Mitigation efforts attempt to minimize long-term effects of the outbreak and apply lessons learned to prevent or minimize the effects of similar events in the future.